Healthcare Provider Details

I. General information

NPI: 1134365489
Provider Name (Legal Business Name): LISSA BROD ANDERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISSA SIMONE BROD M.D.

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 YAKIMA AVE STE 208
TACOMA WA
98405-4499
US

IV. Provider business mailing address

1802 YAKIMA AVE STE 208
TACOMA WA
98405-4499
US

V. Phone/Fax

Practice location:
  • Phone: 253-985-2722
  • Fax: 253-985-2853
Mailing address:
  • Phone: 253-985-2722
  • Fax: 253-985-2853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD29211
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD60222384
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2084H0002X
TaxonomyHospice and Palliative Medicine (Psychiatry & Neurology) Physician
License NumberMD60222384
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: